When something is surrounded by stigma, not talking about it comes naturally. From topics as charged as knowing someone going to prison to others as benign as dealing with a child’s bedwetting, avoidance can feel like the most reliable way to cope. But when we buy into a pattern of “Yikes, let’s not talk about that!”, are we complicit in social oppression? Submarining a conversation is surely incompatible with elevating understanding, but most of us simply feel uncomfortable talking about things we worry will make others uncomfortable. The “#MeToo” movement is an extraordinary example of the inertia needed to break open a taboo topic. From Hollywood celebrities to USA women’s gymnastics stars, it was clear that as more women spoke up about sexual harassment, well, the more women spoke out. As unnatural as it felt to talk about being harassed or abused, many simply acknowledged that it was the courage of their peers that helped them find their courage.
How are we doing as a profession, and as family members and citizens, speaking up about addiction? As I was preparing to lead a conference focused on the opioid epidemic, I was weighing how much time to allow for personal reflections during our sessions. After all, if stigma–and related silence–is a barrier to action, what better place to model what open discussions could look like than at a convening of health professionals? For an incisive essay on how easy it is for “in-groups to mark outgroups as different” and how facile we are in avoiding outgroups, read Goldberg’s “On Stigma and Health.” So, I wondered, would it be indiscreet to ask how addiction has touched the lives of our participants? I decided to put my trepidation to the test at a luncheon attended by twelve health promotion professionals, most of whom were meeting each other for the first time. I initiated a round-robin discussion by saying: “I’m hosting a Think Tank attended by employers to discuss addiction and opioids in the workplace. Do you think I should ask about how addiction affected their lives? And, only if you are comfortable with it, perhaps you can share what you would say at such a session?”
To a person they each shared personal stories, both poignant and hopeful, that made it clear that they put openness above privacy when it came to dealing with the stigma surrounding addiction. Why was I so surprised? I am the author of a book entitled, “Breaking Stone Silence: Giving Voice to HIV Prevention in Africa,” and have discussed AIDS with hundreds of Africans both living with and affected by the epidemic. By now one would think that I would have become inured to the caprices of individual and cultural differences relating to stigma, private lives and public education. Nevertheless, I doubt I’m alone in my bewilderment at the deep irony that stigma commands: where peer pressure is what likely keeps us quiet, peer support is what enables us to speak up.
“If it’s mentionable it’s manageable.” Fred Rogers
Those who are family survivors of the opioid epidemic are often the most effective and outspoken advocates because they feel compelled to share their stories. It’s a form of healing for many. Others are finally confronting the stigma and their own silence that, in retrospect, they partially blame for losing a loved one. I have been surprised at the number of employers I have asked about opioids in their workplace who have said, “we haven’t yet seen it as a problem here.” At the height of the Global HIV/AIDS Epidemic, America’s Surgeon General C. Everett Koop published an AIDS brochure that he sent to every American household. He was vilified by many for publicizing what they viewed as a disease of immorality. What he was eventually celebrated for by most was more than moral courage. As a leader and healer, he understood how keenly linked public awareness and education were to overpowering stigma. He also knew that talking about condoms would not happen between people who didn’t know that deadly STD’s were proliferating. My goal for my full editorial on “breaking the silence” about opioids was to equip readers with opioid education resources that enable you as leaders and silence-breakers to role model what it looks like to speak out about addiction. Some of the resources I reviewed included:
- Surgeon General Jerome Adam’s interview on this topic in the “Voices of Leadership” series at the Harvard T.H. Chan School of Public Health.
- The “Working Well toolkit” that discusses how stigma and the related silence about mental health issues is a key underlying impediment to business success.
- Sam Quinones’ 2015 book, “Dreamland: The True Tale of America’s Opiate Epidemic,” is the most comprehensive reportage to date for explaining how painkillers have led to heroin addiction in America. I was so enthralled by the depth of his reporting that I’ve come to liken “Dreamland” to Rachel Carson’s “Silent Spring.”
- “Pain in the Nation” report details state by state statistics foretelling the inexorable links between issues like alcohol, drugs, and suicide. This comprehensive pain report, details how overdosing has run amok making it a problem resides with all of us.
- PBS aired a powerfully rendered blend of journalistic investigation into the march of the epidemic alongside poignant stories about lives affected by addiction. Simply called, “Understanding the Opioid Epidemic,” this PBS program is a crash course in the current state of affairs of opioid use, a crisis that now knows no boundaries relating to class, race or religion.
Prevention as the Cure
Most addictions like tobacco use, eating disorders and alcoholism grow along a continuum. Looking way upstream, Dayna Bowen Matthew, a Fellow at Brookings, writes in “Unburying the Lead” that social problems like unemployment and affordable housing are the underrepresented precursors to drug abuse prevention. She argues that investing in social risk reduction activities, like promoting social skills and health behavior in our youth, are as vital to slowing the epidemic as are more usual recommendations, like reforming formulary management practices. As with all acts of prevention, the benefit of stopping or slowing new opioid cases will be unknowable. Still, as ach of the resources I describe in more detail in my full editorial has shown, breaking the silence about addiction is needed because “pain killers kill more than pain.” That much we now know for sure.
Read on for my Full Editorial “Breaking the Silence and Other Prevention Lessons from the Opioid Epidemic.” Open access in the American Journal of Health Promotion.
Paul E. Terry, Ph.D., Editor in Chief, the American Journal of Health Promotion, President and CEO, the Health Enhancement Research Organization (HERO)
 Goldberg, D. “Stigma and Health.” The Journal of Law, Medicine and Ethics, Winter 2017, 45: 475-483. http://journals.sagepub.com/doi/abs/10.1177/1073110517750581?journalCode=lmec (accessed 2/5/18)
 Terry, P. “Breaking Stone Silence, Giving Voice to AIDS Prevention in Africa.” Africa World Press. http://africaworldpressbooks.com/breaking-stone-silence-giving-voice-to-aids-prevention-in-africa-by-paul-terry/ (accessed 2/5/18)
 “Voices in Leadership” Live stream. “A Conversation on the Opioid Epidemic with Vice Admiral Jerome M. Adams, 20th Surgeon General of the United States.” https://www.hsph.harvard.edu/voices/events/jerome-adams-20th-surgeon-general-of-the-united-states/ Harvard T.H. Chan School of Public Health. Jan. 24, 2018. (accessed 1/24/18)
 “Working Well: Leading a Mentally Healthy Business.” Working Well Toolkit. June, 2016. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjyzOKL9vPYAhWE6YMKHY9IBu4QFggpMAA&url=http%3A%2F%2Fworkplacementalhealth.org%2Fgetattachment%2FMaking-The-Business-Case%2FLink-2-Title%2Fworking-well-toolkit.pdf%3Flang%3Den-US&usg=AOvVaw2JwMpsR_joTGObP6p5DZNe (PDF; accessed 1/25/18)
 Quinones, Sam. “Dreamland: The True Tale of America’s Opiate Epidemic,” 2015, Bloomsbury Press, 1385 Broadway, New York, NY, 10018, USA.
 “Pain in the Nation: The Drug, Alcohol, and Suicide Crises and the Need for a National Resilience Strategy.” A collaboration between Trust for America’s Health, Robert Wood Johnson Foundation, and Well Being Trust. http://wellbeingtrust.org/for-media/pain-in-the-nation-report (accessed 1/19/18)
 Grant, John. “Understanding the Opioid Epidemic,” PBS, January 17, 2018. Copyright 2015, Public Broadcasting Service. http://www.pbs.org/show/understanding-opioid-epidemic/ (accessed 1/19/18)
 Bowen Matthew, Dayna, “Unburying the Lead: Public Health Tools are Key to Beating the Opioid Epidemic.” Center of Health Policy, Brookings. https://www.brookings.edu/research/un-burying-the-lead-public-health-tools-are-the-key-to-beating-the-opioid-epidemic/ (accessed 5/5/18)